Element3 Health, Inc. d/b/a Grouper, a Delaware corporation (“Grouper”, “we”, or “us”) is always pleased when our members are willing to share their stories and first-hand experiences as members of social activity groups. Sharing your story can help to foster connections with others and can help to highlight the health-related benefits that result from social activity. In order to share your story with both internal and external audiences, we request your consent to use information about you and your experience participating in social activity groups. PLEASE REVIEW THIS FORM IN FULL AND SIGN BELOW TO INDICATE YOUR CONSENT. We will keep a copy of the signed consent for our records.
I consent and give my permission for Grouper to use information concerning my experience as a member of social activity groups (“My Information”) in connection with any communications produced by or on behalf of Grouper. I understand that My Information includes without limitation my name, image, likeness, as well as other information provided by me and about me, which may be in the form of quotations, written materials, photographic material, audio files, and videos. I understand that the communications produced by or on behalf of Grouper that use or incorporate My Information may be used internally within Grouper or externally outside of Grouper, such as used on Grouper’s publicly-available website, on social media sites, in mailings to prospective customers, etc.
I consent and give my permission for Grouper to release My Information to the news and media outlets, which include without limitation internet/online publications, TV, radio, newspapers and/or magazines, and to allow the news and media outlet to use or make images (digital, video, or otherwise) of me for purposes of illustrating my experience as a member of social activity groups and any associated health-related benefits.
I understand that I am not required to sign this form. Grouper does not condition its services or my eligibility for enrollment in activities on the signing of this form. I understand that I will not be entitled to any payment or other form of remuneration as a result of any use of My Information or any resulting communication or any print/photographic/audio/video material developed by Grouper.
If I decide to sign this form, I have the right to request that audio/video recording, filming, or photographing of me cease at any time. I understand that information about me used or disclosed pursuant to this consent form may be used in perpetuity and may be subject to re-disclosure by the recipient.